New endoscopic technologies improve outcomes of UGIB
New endoscopic technologies have improved outcomes for patients with upper gastrointestinal bleeding (UGIB), according to Professor James Lau from the Chinese University of Hong Kong, who reviewed current treatment practices and latest advances at the Asian Pacific Digestive Week (APDW) 2017 held recently in Hong Kong.
“Injection therapy with diluted epinephrine, introduced in the 1980s, has been shown to reduce the need for surgery and transfusion and shorten hospital stay,” said Lau. “Some years later, we realized that it could be improved by adding a second modality, such as clips or thermo-coagulation. A meta-analysis published in 2004 showed that a second modality not only reduced recurrent bleeding and surgery, but also decreased mortality by 50 percent. Hence, the current standard is to add a second modality targeting the vessel itself.” [Br Med J 1988;296:1631-1633; Gastroenterology 2004;126:441-450]
When selecting between clips or thermo-coagulation, a meta-analysis showed no significant difference in terms of bleeding control. [Gut 2007;56:1364-1373]
“An improved clip that opens to about 2 cm provides very nice results. You target at the base of the bleeding point and push in firmly to apply the clip. Two or three clips are usually required,” said Lau. “Coaptive thermo-coagulation, which involves irrigation, pressure on the artery and thermal energy, is a technique that withstood the test of time as it is still being used.” [Gastroenterology 1987;92:1101-1108]
The use of haemostatic powder spray is effective in acute nonvariceal gastrointestinal bleeding (ANVGIB). “There are no published randomized trials, but a summary of the literature indicates that the initial bleeding control rate approaches 90 percent. Unfortunately, the rebleeding rate is 20 percent. The current recommendation therefore suggests haemostatic powder to stop the bleeding, allowing time for second-look endoscopy and treatment of residual stigmata,” noted Lau.
Over-the-scope clips (OTSCs) have been shown to improve initial bleeding control vs standard endoscopic therapy (96 vs 62 percent) and reduce 7-day rebleeding (24 vs 33 percent.) “There is an indication that OTSCs are useful in rebleeders, but we are waiting for the full study report,” he remarked.
The Apollo Overstich – a device for internal gastric plication used in obesity surgery – has been applied for bleeding gastric ulcers with limited success, due to the technical expertise required and high rebleeding rates.
Advances in identifying the stigmata of recent haemorrhage (SRH) have also improved treatment outcomes. “While in the past we relied on visual interpretation with Forrest classification, new devices such as a disposable ultrasound probe or Doppler probe can better identify arterial flow and additional signals. For example, Doppler probe can identify nearly 70 percent of clots and 40 percent of flat spots,” explained Lau. “A recent study suggests that Doppler-guided endoscopic treatment is superior to standard therapy, but this needs to be validated in a larger series.” [Gastroenterology 2017;152:1310-1318]
“Reporting of endoscopic ultrasound-guided angiotherapy remains anecdotal, but it is an interesting concept that may be useful in selected patients,” he suggested.